University of Manchester
Year 5 Medical Students (Ethics & Communication)
Ethics in Action
Negotiating Solutions to Ethical Dilemmas using
Communication Skills
Revised by Ruth Bromley July 2014
Based on original work by Caroline Boggis, Rosie Illingworth and Mark Perry
Negotiating Solutions to Ethical Dilemmas Year 5 2014 - 15
Contents
Outline of session....................................................Page 3
ILO’s...............................................................................Page 3
Timetable.....................................................................Page 4
Administrator’s planner.........................................Page 4&5
Organisational Information..................................Page 5
SP Rota............................................................................Page 6
Instructions to lead tutor........................................Page 7
Instructions to tutors................................................Page 7-9
Key questions...............................................................Page 10 tudent Handout (1)
Cases with tutor notes...........................................From Page 12
DVLA epilepsy Dr p 11 / SP 12/ Tutor p 13-14
Safeguarding Dr p 15/ SP p 16-18/ Tutor p 19
15 yr with diabetes Dr p 20/ SP p 21/Tutor p 22-24
A Colleague in Difficulty Dr p 25/ SP p 26/Tutor p 27-29
Bibliography................................................................Page 30
Student Handout........................................................Page 31 Student Handout (2)
Includes additional case material………………Page 33
Outline of session
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Negotiating Solutions to Ethical Dilemmas Year 5 2014 - 15
This is a 3 and a half hour session which allows students to practise using their
communication skills within ethical scenarios. After a brief introduction for the whole
group, which summarises their learning to date, and outlines the plan for the session,
the students will break into groups to practise 4 scenarios. The session ends with a
plenary session which gives the students further opportunity to discuss unanswered
questions.
ILO’s
By the end of this session, the students will have gained experience of applying their
ethical knowledge to reasonably common clinical scenarios. They will have observed
(and, in some cases, practised) using good communication skills eg listening, empathy,
exploring ideas, concerns and expectations to negotiate management/patient care.
Epilepsy
Mr/Ms Smith
To explain the conflicting ideas of patient autonomy and personal liberty
vs dr’s obligation to act to protect patient safety
To demonstrate knowledge of the relevant DVLA guidelines re Epilepsy
and GMC guidance re Good Practice
To demonstrate the ability to elicit the pt’s ideas and concerns
To demonstrate the ablity to sensitively handle and explain the reasons
why the pt can’t drive and to advise the patient in-line with current
guidance
Safeguarding
To listen to and understand the patient’s concerns
Mrs Birchwood
To sensitively and appropriately handle the patient’s concerns with due
reference to the limitations upon Confidentiality
To be able to understand and demonstrate the necessary knowledge for
Safeguarding of vulnerable adults and children in this scenario
To demonstrate safe practice for this level of training ie referring
onwards appropriately and promptly
To experience hearing a story, and taking information, in this very
difficult and sensitive situation
Diabetes
Daniel/Danielle
Diabetes cont’d
To demonstrate knowledge of the guidance around consent and refusal
for treatment in under 16’s and concept of capacity as per Fraser
guidelines and to institute this into clinical practice.
To demonstrate a knowledge and understanding of GMC guidance and
best practice regarding Children
To use rapport to facilitate communication
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Negotiating Solutions to Ethical Dilemmas Year 5 2014 - 15
To accept/assess the pt’s capacity and work with it
To demonstrate the ability to negotiate a compromise whilst
maintaining relationship
Colleague in
Difficulty
To demonstrate and understanding of the limits upon autonomy in
relation to patient safety
Mr/Mrs Williams
To demonstrate knowledge and understanding of their duty of care as
per GMC guidance on ‘Duties of a Doctor’
To demonstrate the ability to adopt a firm but supportive stance
To demonstrate the ability to listen carefully to what their colleague has
to say and to elicit their preferences around treatment options
To demonstrate that, if their colleague will not act to put patient safety
first, then they will be prepared to
Timetable Negotiating Skills (Ethics)
Updated June 2012
Running Duration What
Time
O mins 15mins Introduction to session and explanation of day.
Basic instructions and details of running, as per
power-point presentation
15 mins 5mins Travel time- break away into smaller groups
20mins 10mins Form group. Hand out ‘key questions’. Allocate
tasks for first case
30mins 30mins Case
1h
30mins Case
1h30mins 15mins Break
1h45mins 30mins Case
2h15mins 30mins Case
Travel time
2h45mins 5mins
2h50mins 40mins Return to main group/room. Plenary. Q&A
3h30mins
The End
Administrator’s planner for theY5 Ethics Course
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Who
Lead tutor
Tutors
Groups
Groups
Groups
Groups
Lead
tutor/All
Negotiating Solutions to Ethical Dilemmas Year 5 2014 - 15
In advance
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E-mail student notes 1 week prior to session
Students must be informed of the dates well in advance and nearer the time
Arrange booking of rooms
Book/arrange refreshments
Confirm/book tutor availability – ideally groups of 10 or fewer students
Book simulated patients and send out scripts.
Prepare grid/timetable for who, where, doing what, when!
Liaise with other staff who may have student teaching at the same time as your
course (essential!)
Photocopy student handouts and a copy of ‘Key Questions’, 1 copy of each per
student – on students’ ipads
Make sure all tutors have tutor notes
Ensure overheads/power point presentation is available/downloaded from master
Sort tutor packs to contain:
Timetable for the course
Grid of who (tutor/group/SP) is where/when each session (ensure no group has the
same role twice!) and copy of room and SP timetable for SPs
Tutor notes – one document covers the whole course including timing of session
Instructions to doctor for each role/case (1 copy for each case for each group)
Allocation of students to groups (list will double as a register)
Name badges (stickers/ computer labels)
Sheets of blank paper (for note taking in the groups)
List of ‘key questions’ for each student Student handout (1 copy per student) – on students’ ipads
Evaluation forms
Sort simulated patient packs to contain:
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Timetable
Grid
Student handout
SP roles for the sessions
Confirm bookings
Organisational information
NB. There is variation between sites re no. of SPs used in each rotation.
Overall group size Any number
Small group size
Ideally 10
Number of groups Increments of 4
Number of SPs
Increments of 4
Rooms
Large room for opening talk/plenary
1 small room/area for each group
Tutors
Lead tutor and 1 tutor per small group
SP Rota
Group
1
Epilepsy
Smith
Diabetes
Daniel/Danielle
Safeguarding
Birchwood
Group
2
Colleague in
Difficulty
Williams
Epilepsy
Smith
Diabetes
Daniel/Danielle
Group
3
Safeguarding
Birchwood
Colleague in
Difficulty
Williams
Epilepsy
Smith
Diabetes
Daniel/Danielle
Group
4
Diabetes
Daniel/Danielle
Safeguarding
Birchwood
Colleague in
Difficulty
Williams
Epilepsy
Smith
Student-led
ie no SP needed
Student-led
ie no SP needed
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Student-led
ie no SP needed
Colleague in
Difficulty
Williams
Safeguarding
Birchwood
Student-led
ie no SP needed
Negotiating Solutions to Ethical Dilemmas Year 5 2014 - 15
Notes to lead tutor
Thank-you for running this session.
Your main role is as ‘ethical’ guide for the introductory scenario and plenary. The
power-point presentation at the outset gives a summary of their progress to date and
then provides the aims & objectives for the session and the running order.
By the time of the second plenary, the groups should have reached some answers for
each case and drawn up a list of unresolved questions. Ask a scribe to begin presenting
these back to the group, a case at a time and then open up the discussion.
If there is time, the students’ feedback has indicated that they would welcome the
opportunity to ask general questions around preparation for OSCE and other ethical
scenarios.
POWERPOINT PRESENTATION ATTACHED AS SEPARATE FILE
Tutor notes
Thank-you for volunteering to facilitate a group.
Your task is two-fold, firstly to keep the group moving, get them organised into roles as
quickly as possible and to time-keep. Secondly, to push their thinking forward and help
them to advance their arguments and decisions.
Guidance on running the small group sessions
Before the first SP arrives
Distribute sticky labels to be used as name badges - ask each student to write the name
that they would like to be known by during the session! Make sure that the chairs are in
a circle and that you are sitting in the circle so that you give the sense of being
collaborative. Give out the ‘Key Questions’ which will be used to focus debrief after each
case.
Explain what will happen in the session. That is you will be visited by 3 simulated
patients and there is one case where a student will take the role of SP; there will be four
interviews and time to give feedback to the interviewer. There is 30mins/case.
Explain that as this is a safe environment.
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Preparing for the role play with the SP
Either ask for a volunteer to conduct the first interview or allocate people for all four
interviews to save time later in the session.
Give the student conducting the interview the doctor’s role notes (and where applicable,
the student acting as SP their notes) – whilst they familiarise themselves with the role,
read the role out to the group. Check if there are any questions or points of clarification
– the students may need to share their knowledge of the illness/condition described in
the role.
A scribe is needed for each case, to note the groups answers to the ‘key questions’ and
to draw up a list of ‘learning needs’ for the plenary. To ensure the other students don’t
passively watch, allocate tasks for giving feedback/analysing each scenario. For
example, each student/pair could be asked to consider one of the ‘key questions’
from the list. Ensure observers make precise notes to enable specific & focused
feedback.
Pause button/rewind facility
Tell the students that they may use an imaginary pause button if they get stuck. This
means they can temporarily come out of the interview to talk with the group about what
to ask next or which areas they may want to pursue.
Reinforce that using the pause button [as often as necessary] is a positive thing to do,
showing that students want to think about the issues/questions.
The student can also rewind the interview and try a different question or approach. The
SP will be ready for this possibility.
The interview
Check that the interviewer is clear about how he/she is going to start. If the student is
not sure, have a brief group discussion to pool ideas. Possible questions for you to ask
the student at the beginning are: ‘How are you going to start?’; ‘What help do you need
before starting?’; ‘How are you going to explain…?’
The interview should last approximately 10 minutes. You can bring it to a close or pause
it if necessary. Keeping to the overall time schedule is crucial.
You could ask other students to have a go at a section of an interview or even ask
students to try something different.
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Feedback/Discussion
It is essential that students reflect upon the ethical and legal content of the cases and their
learning needs that arise. The KEY QUESTIONS are specifically designed to facilitate this
process. However, communication is an essential skill in managing these scenarios and so
relevant feedback on consultation style will also be important. Tutors have an essential
role in facilitating discussion towards the key ethical issues.
We generally use Pendleton’s Feedback Rules. First, the student interviewer reflects
on what he/she did well. Then the group also suggests what was done well. The SP in
role should be invited to contribute to this aspect of the feedback. The next phase is for
the interviewer to reflect on what could have been done differently. Contributions
should again be made by the group and the SP.
NB. Some students will express an alternative preference for how they receive feedback
and what they receive feedback on- this may need to be negotiated on a student-bystudent basis.
At the end of each case, ask the group to summarise the key learning points and identify
an ‘action plan’ for further learning. Ask the scribe to note these down, this will form the
basis of the plenary.
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Key questions for use in groups
(1) What are the ethical/legal components of this case?
(2) What ethical/legal KNOWLEDGE is required?
(3) What sources of information are needed to resolve this case? Eg support from a
clinician, reference to relevant documentation
(4) What is the ‘right’ answer? In philosophical terms, what is the ‘morally correct’
answer?
(5) How can communication skills best be employed to give a positive outcome in
this case?
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Case: DVLA/Epilepsy (Mr(s) Smith)
Student instructions
You are an FY2 in Neurology. You are about to start an out-patient clinic. You are about to review
Mr/Mrs Smith, a patient that you have not met before. They were presented on the ward round
whilst they were in hospital but you had to go and answer an emergency bleep that day. You know
that they were admitted for investigations of episodes of collapse and diagnosed with Generalised
Tonic-Clonic Seizures. They had 2 seizures, a few days apart, whilst on the ward. They were
discharged 4w ago on Epilim chrono 300mg bd. Prior to admission, they were working as a taxi
driver.
Before you call them in, the nurse in clinic informs you that as she came into work she saw Mr/Mrs
Smith parking their taxi in the hospital car park. It is documented in the records that the patient has
been advised to tell the DVLA about their new diagnosis and advised of the current DVLA guidelines.
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DVLA/Epilepsy- Simulated patient
Patient’s name
Setting
Age
Sex
Mr/Mrs Smith
Neurology out-patient clinic
25-50
M or F
Background
25-50 year old male/female with 4 children (pick suitable ages) and a partner who does not work
outside the home. You have always earned your living as a self-employed taxi driver. You have
always worked hard but maintained a reasonable standard of living for your family. You own your
home, with a mortgage. You have some credit card debts and a loan on your car. You have never
seen the point of Critical Illness Insurance. You are tee-total.
Recent Past
You were admitted to hospital a month ago after a 6 week period where you had collapsed several
times. You have been diagnosed with epilepsy (Generalised Tonic Clonic Seizures). You had 2
seizures, a few days apart, on the ward. You were discharged 4 weeks ago. Since then, you have
been taking Epilim Chrono (a long-acting 300mg tablet) twice a day without fail.
When you were in hospital, you were told that you need to tell the DVLA about your diagnosis. You
were warned by several clinicians that you should not drive and that in order to be a taxi driver
again, you would need to have stopped medication for 10 years AND have had no more fits during
this time. You think this is ridiculous as you feel fine. This illness is a devastating blow to you and
your family as your only source of income is from driving. You have not had any fits since discharge
from hospital. As a result, you have continued to drive a few hours a day. You feel guilty about this
as you know that it is against medical advice, but you need the money and are feeling quite well.
You do have some niggling worries about what would happen if you had another fit whilst driving.
You are quick to reassure anyone who shows concern for your well-being, friends, family and
clinicians alike, that you are fine. You don’t like any fuss or attention and are certainly not prepared
to be held back by an illness like epilepsy. You are not in denial so much as keen to get your life back
to ‘normal’ as soon as possible.
Role play behaviour
When challenged by the doctor about your driving, accept responsibility but downplay the
significance. The student may need a cue eg ‘What will you do if I don’t stop driving?’. Your tone
should be civil but perhaps a little too light-hearted. You should not be easily persuaded to inform
the DVLA about your diagnosis of epilepsy and only concede at the point that the doctor has advised
you that if you will not tell then they will. If they are persuasive in their reasoning as to why you
should not drive, express your frustration and fears but agree to stop immediately and inform the
DVLA.
If the doctor does not give you the opportunity to inform the DVLA yourself, then ask them if there is
another option.
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Case notes for tutor
Front-of-house: Mr(s) Smith
Key ethical features *Conflict of pt’s autonomy and personal liberty vs dr’s obligation
to act to protect patient safety
Key knowledge *DVLA guidelines re Epilepsy
*GMC guidance re GMP/Confidentiality
Candidate expectation *Elicit the pt’s ideas and concerns
*Explaining the reasoning why pt can’t drive
*Know GMC/DVLA guidelines and advise pt accordingly
Relevant documents
From www.dvla.gov.uk medical rules ‘At a glance’ 2014
Pt has duty to inform DVLA themselves but see below re. public interest and guidance from
GMC re DVLA.
Epilepsy- more than 1 fit, more than 24h apart, 12m fit-free on/off tx with medical
assessment prior to resuming driving. Will be issued a 3y license, rolling until 70y. DVLA must
be informed. For taxi driver to resume working, although this is licensed by local authorities,
DVLA advised that best practice is to invoke Group 2 ie HGV/PGV limitations. For epilepsy, pt
must be fit-free, OFF TREATMENT, for 10 years.
From GMC Confidentiality (2009)
For best guidance please look on-line at this PDF:
http://www.gmc-uk.org/Confidentiality_reporting_concerns_Revised_2013.pdf_52091821.pdf
And basic overlying principles outlined below… http://www.gmcuk.org/guidance/ethical_guidance/confidentiality_36_39_the_public_interest.asp#36
Confidentiality guidance: The public interest
Disclosures in the public interest
1.
36. There is a clear public good in having a confidential medical service. The fact
that people are encouraged to seek advice and treatment, including for
communicable diseases, benefits society as a whole as well as the individual.
Confidential medical care is recognised in law as being in the public interest.
However, there can also be a public interest in disclosing information: to protect
individuals or society from risks of serious harm, such as serious communicable
diseases or serious crime; or to enable medical research, education or other
secondary uses of information that will benefit society over time.
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2.
37. Personal information may, therefore, be disclosed in the public interest,
without patients’ consent, and in exceptional cases where patients have withheld
consent, if the benefits to an individual or to society of the disclosure outweigh
both the public and the patient’s interest in keeping the information confidential.
You must weigh the harms that are likely to arise from non-disclosure of
information against the possible harm both to the patient, and to the overall trust
between doctors and patients, arising from the release of that information.
3. 38. Before considering whether a disclosure of personal information would be
justified in the public interest, you must be satisfied that identifiable information is
necessary for the purpose, or that it is not reasonably practicable to anonymise or
code it. In such cases, you should still seek the patient’s consent unless it is not
practicable to do so, for example because:
a. (a) the patient is not competent to give consent, in which case you should
consult the patient’s welfare attorney, court-appointed deputy, guardian or
the patient’s relatives, friends or carers (see paragraphs 57 to 63)
b. (b) you have reason to believe that seeking consent would put you or
others at risk of serious harm
1.
c.
(c) seeking consent would be likely to undermine the purpose of the
disclosure, for example, by prejudicing the prevention or detection of
serious crime, or
d.
(d) action must be taken quickly, for example, in the detection or control
of outbreaks of some communicable diseases, and there is insufficient time
to contact the patient.
39. You should inform the patient that a disclosure will be made in the public
interest, even if you have not sought consent, unless to do so is impracticable,
would put you or others at risk of serious harm, or would prejudice the purpose of
the disclosure. You must document in the patient’s record your reasons for
disclosing information without consent and any steps you have taken to seek the
patient’s consent, to inform them about the disclosure, or your reasons for not
doing so.
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Case: Safeguarding
Student Instructions
You are an F1 doctor on a surgical firm. Mrs Birchwood was admitted to hospital last week
with severe abdominal pains. After a CT scan, she was diagnosed with bowel cancer that has
spread to her liver. She will be referred to Christie for chemo but will not be having an
operation. Her prognosis is approximately 12 months. She is fully-informed.
She has been quite unwell so it is likely that she will be in hospital for more another week.
The Consultant has advised her about this on the ward round this morning.
After the ward round, the nurse on the ward informs you that Mrs Birchwood has asked to
speak with a member of the team urgently. You are the only one on the ward.
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Safeguarding: Information for Simulated Patients
Patient’s name
Setting
Age
Sex
Mrs Birchwood
Surgical Ward
50ish
F
Background
Elaine Birchwood (nee Gittins). You have raised 3 children and always worked part-time in
the local newsagents. You were happily married for 25 years. Your parents both died when
you were young (your mum had ovarian cancer and your dad then had a heart attack 1y
later and died). You don’t have any family nearby- you have a brother who emigrated to
Australia when he was 18 years old.
Your husband died 2 years ago from a sudden heart attack. Steve dropped dead on the front
path when putting the bins out. You have found this whole time period extremely stressful.
You have not really grieved yet due to the problems with your youngest daughter Sarah.
Sarah is 22 years old, has always been wayward and a handful but responded much better
to her dad. She left school aged 15, got in with the ‘wrong crowd’ including her ex-partner.
You have a stressful relationship, where you feel like you give and Sarah takes. She can be
very loving at times but will not listen or respond to advice.
You have 2 other children, a 24 year old son Paul who is in the army, currently on tour in
Afghanistan and a 26 year old daughter Lucy who lives in London. She is a lawyer. She does
not visit often.
Medical History
You were admitted as an emergency through A&E last week with vomiting that wouldn’t
settle. You have now been in hospital for 1 week and have just been diagnosed with bowel
cancer. It has spread within your abdomen and to your liver. You will be going to Christie to
see if you can have chemo but there is no possibility of an operation. You know that you will
die from your illness but may have 12 months to live with chemo.
In the last 3 months, you have been experiencing increasingly severe abdominal bloating
and pain but at the same time can see that you are losing weight, especially from the
appearance of your hands and face. Your skin looks a little yellow. You have lost your
appetite and cannot eat much in one go without feeling very full.
Prior to this, you have always been well, with no significant illnesses and you do not take
any regular medication.
NB Students will not be taking a full history but any other questions would result in a
‘normal’ response eg bowels, passing urine etc.
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Recent Family Events
Due to some very challenging circumstances at home you have been trying to ignore your illhealth in the hope that you might get better.
Your daughter, Sarah, has 3 boys, Tom, Jake and Reilly aged 5 months, 2 years and 4 years
respectively.
Sarah’s ex-partner Sean, the children’s father, was extremely violent and abusive. The
children were frequently in the house or same room when he was violent and he assaulted
her twice during her last pregnancy, on one occasion breaking her jaw. After a long and
very stressful period of police and social services involvement, Sarah has just recently come
back to live in the family home with you.
You love Sarah, and fear for her future, but are weary and distressed by all the trouble she
has brought in recent years and can’t help feeling that some of it is of her own making. Your
primary concern is for the boys’ well-being. You adore them- they have been your solace
since Steve died. You are resigned to the fact that Sarah might not be allowed to keep them
in her care if she has any further intervention from social services but, prior to your illness,
you would have been determined to take on their care yourself if that situation arose.
Just before you were admitted, you found out that your daughter is back in contact with her
ex-partner. You also have your suspicions that your daughter is smoking cannabis. She has
been going missing for hours on end, leaving the babies in your care.
Your very close friend, and next-door-neighbour, Pauline, visited yesterday, bringing
supplies (nightclothes and toiletries) from your home (she has a key). She said that when
she went to your house she found the baby asleep in the cot, with Sarah nowhere to be
found. Sarah returned with the other 2 children 30minutes later saying she had just popped
out to get some more nappies. Sarah had a black eye.
You are terrified that if the police or social services are involved again, then the children will
be taken into care, especially now that you are too unwell to take on the children’s care.
Social Services/Legal Position
You have a social worker, Sandra Brown. She is in regular contact.
The children are on the Child Protection Register (risk of physical abuse). In order for Sarah
to be able to keep the children, you have accepted legal (parental) responsibility for your
grandchildren. She is allowed to remain involved in their care under the proviso that she
lives with you and does not see her ex-partner. There are regular Child Protection
Conferences to check that the terms of the Child Protection Plan are being met.
Given the events of the last few days, and your illness, Sarah has potentially jeopardised her
right to ‘keep’ her children.
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Role Play
You have seen the doctor that comes to see you on ward rounds with your Consultant but
have not talked on a one-to-one basis before. You had asked to speak to a member of your
medical team urgently.
Whilst you have been in hospital, you have already had good reason to worry about your
grandchildren’s futures. Yesterday’s events were the final straw. You need someone else to
know what you are worrying about but know if you speak to Sandra, the children will be
taken straight into foster care. You are hoping, although deep down you know that it’s in
vain, that social services do not need to be involved and that there may be another way you
can solve this dilemma. You desperately need the doctor’s help and support.
You know that something has to be done. You are afraid for Sarah but your over-riding
concern is for the children and for your legal and grandmotherly responsibilities.
Opening Gambit
Please start by interrupting any opening statement that the student might offer,
encouraging them to sit down and insisting that they listen to your worries (hopefully this
will avoid the student offering false reassurances about Confidentiality!).
Eg ‘Please doctor, come and sit down, I need to talk to you. I’m just so worried about…’
At the end of this, then add ‘But you won’t tell Social Services will you?’
The idea of the case is to test that they can explain to you that either you or they will need
to involve social services and senior colleagues so they should make an attempt to explain
that to you. Please challenge any original assertion with ‘I was hoping that we could sort
this out ourselves. I could ask Sarah to come in and then maybe you could tell her to stop
seeing Sean?’ or such like.
Towards the end of the conversation, ask the student what will happen next so they can
demonstrate that they have made a plan.
Key points for Role Play (with thanks to Elaine Proudman and Ella Burton)
From the initial pilot, it was felt the important information to disclose to the student at the beginning , with as little
interruption as possible was, as follows :

You have to get it off your chest and tell someone. Because it has to be sorted out. Use your pressure of
speech as a way of stopping them from going into confidentiality!

Use the fact that you have been told on the ward round that you will be in hospital for another week as the
reason why you need to talk to the doctor immediately.

Inform the student about what you have been told by your friend, and refer to details of the ex- partner’s past
violent behaviour. Also, inform the student that this is why your daughter and her children are living with you.

Tell the student of your worries about the children being taken into care, and inform them about your
responsibility to the children with regards to the ‘interim care order’.

If you get a chance, tell them that you had noticed your daughter going missing recently and your suspicions
about the ex-partner and the cannabis use.
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Case notes for tutor
Safeguarding
ILOs
(1) To listen to and understand the patient’s concerns
(2) To sensitively and appropriately handle the patient’s concerns with due reference to
the limitations upon Confidentiality
(3) To be able to understand and demonstrate the necessary knowledge for
Safeguarding of vulnerable adults and children in this scenario
(4) To demonstrate safe practice for this level of training ie referring onwards
appropriately and promptly
(5) To experience hearing a story, and taking information, in this very difficult and
sensitive situation
Ethical Issues
(1) The limits to the Confidentiality that the doctor can offer once a patient has revealed
risk to a child
(2) The doctor’s responsibility to explain sufficiently to the patient the limits to
Confidentiality
(3) The duty to act to Safeguard children, which overrides any patient’s right to
Confidentiality
(4) The difficulty in balancing/prioritising need in a clinical setting
Candidate expectation
This is a deliberately difficult and challenging case and the key aim is for the students to
have had exposure to this type of case material. The outcome is less important than
their reflections and the group discussion that follows the role play.
The students should be able to discuss the limits of Confidentiality with regards to a
serious Safeguarding issue but it will be expected that part of their management plan is
to seek senior support immediately.
http://www.gmcuk.org/publications/standards_guidance_for_doctors.asp#Protectingchildrenandyoungpeople
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15y old with diabetes
This case will be role-played by 2 students, one as doctor, one as patient
Student instructions for Doctor
You are an FY2 on a Paediatric ward. You have been looking after 15y old Daniel/Danielle for the last
2 weeks. They have suffered with diabetes throughout their teens and have had multiple admissions
as a result of this. They have been less than compliant lately, preferring to go out and drink in the
park with their mates. On this occasion, they were admitted through A&E with hypoglycaemia,
having been found collapsed and drunk in the park by the police. Their parents are very supportive
but somewhat despairing as they can see how awful this is for their son/daughter but have concerns
about their long-term health.
Daniel/Danielle’s diabetic control has been erratic during admission and your consultant wants to try
a new insulin regimen which involves injections four times a day, instead of twice a day (which has
never been ideal, but was all that Daniel/Danielle would accept). Despite the best efforts of the
multi-disciplinary team, Daniel/Danielle is refusing to even entertain this idea.
You have sat up for several nights when on-call playing computer games and talking about music
with Daniel/Danielle and your consultant is aware that you have a good rapport. In a final attempt to
influence their decision, your consultant has asked you to talk with them and see if a compromise
can be reached.
Try to uncover their concerns and see if there is any common ground upon which you can negotiate.
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15y old with diabetes
This case will be role-played by 2 students, one as doctor, and one as patient
Patient role
Background You are a well-loved but somewhat stroppy teenager who has been testing boundaries
lately. You come from a stable, comfortable family background and will leave school with good
qualifications next year. You hope to go to Uni.
You have suffered with diabetes throughout your teens and have had multiple admissions as a result
of this.
You have a good friendship group and hang out at weekends. You have started to experiment with
alcohol lately and have had the odd cigarette and joint. You resent how your diabetes singles you
out from your friends. You resent that your parents have to prompt you to take regular meals and
medication. You don’t care about the future; you just want to be like your mates. You are in a new
relationship and worry that you might be dumped if you are perceived to be weak or ill.
You have been less than compliant lately, preferring to go out and drink in the park with your mates.
On this occasion, you were admitted through A&E with hypoglycaemia, having been found collapsed
and drunk in the park by the police. Your parents are very supportive but somewhat despairing as
they can see how awful this is for you but have concerns about your long-term health.
Your diabetic control has been erratic during admission and your consultant wants you to try a new
insulin regimen which involves injections four times a day, instead of twice a day.
Personal Behaviour You like the doctor who is coming to speak to you, they are not such an
authority figure as the Consultant, who you also know well. They seem more in tune with you and
your generation. However, you are an ‘expert’ in your diabetes and know what they are going to try
to convince you to do. Whilst you are happy to continue to take insulin twice a day, you are not,
under any circumstances, going to take it four times a day.
Role play behaviour Really make the most of the chance to re-live your teenage days. Be as uncooperative and monosyllabic as you wish. You are going to take some cajoling even to discuss your
diabetes with this doctor.
You are more than happy to chat with this doctor. You have a good relationship with them. The
bottom line is that you will not allow yourself to be discharged on four times a day injections but you
might be prepared to come back to clinic next week to discuss this further.
You should remain challenging, using statements like ‘There’s nothing you can do to make me do
what you want!’
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Tutor notes 15y old with DM- Daniel(le)
Key ethical features *knowledge of the guidance around consent and refusal for
treatment in under 16’s and concept of capacity as per Fraser guidelines.
Key knowledge *GMC guidance and best practice re Children
Candidate expectation *use rapport to facilitate communication
*accept/assess the pt’s capacity and work with it
*negotiate a compromise whilst maintaining relationship
Relevant information
0-18 years: guidance for all doctors
Making decisions:
Assessing the capacity to consent
24. You must decide whether a young person is able to understand
the nature, purpose and possible consequences of
investigations or treatments you propose, as well as the
consequences of not having treatment. Only if they are able to
understand, retain, use and weigh this information, and
communicate their decision to others can they consent to that
investigation or treatment.5 That means you must make sure
that all relevant information has been provided and thoroughly
discussed before deciding whether or not a child or young
person has the capacity to consent.
25. The capacity to consent depends more on young people’s ability
to understand and weigh up options than on age. When
assessing a young person’s capacity to consent, you should
bear in mind that:
a.
at 16 a young person can be presumed to have the
capacity to consent (see paragraphs 30 to 33)
b.
a young person under 16 may have the capacity to
consent, depending on their maturity and ability to
understand what is involved.6
26. It is important that you assess maturity and understanding on
an individual basis and with regard to the complexity and
importance of the decision to be made. You should remember
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that a young person who has the capacity to consent to
straightforward, relatively risk-free treatment may not
necessarily have the capacity to consent to complex treatment
involving high risks or serious consequences.* The capacity to
consent can also be affected by their physical and emotional
development and by changes in their health and treatment.
If a young person refuses treatment
30. Respect for young people’s views is important in making
decisions about their care. If they refuse treatment, particularly
treatment that could save their life or prevent serious
deterioration in their health, this presents a challenge that you
need to consider carefully.
31. Parents cannot override the competent consent of a young
person to treatment that you consider is in their best interests.
But you can rely on parental consent when a child lacks the
capacity to consent. In Scotland parents cannot authorise
treatment a competent young person has refused.10 In
England,Wales and Northern Ireland, the law on parents
overriding young people’s competent refusal is complex.11 You
should seek legal advice if you think treatment is in the best
interests of a competent young person who refuses.12
32. You must carefully weigh up the harm to the rights of children
and young people of overriding their refusal against the benefits
of treatment, so that decisions can be taken in their best
interests.13 In these circumstances, you should consider
involving other members of the multi-disciplinary team, an
independent advocate, or a named or designated doctor for
child protection. Legal advice may be helpful in deciding
whether you should apply to the court to resolve disputes about
best interests that cannot be resolved informally.
33. You should also consider involving these same colleagues
before seeking legal advice if parents refuse treatment that is
clearly in the best interests of a child or young person who
lacks capacity, or if both a young person with capacity and their
parents refuse such treatment.14
from : www.gmc-uk.org/guidance/ethical_guidance/children_guidance_index.asp
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ie a parent cannot over-ride a competent child’s refusal of treatment.
In this case, I would deem that a compromise should be sufficient to move Daniel(le)’s
care forward and that the greater risk to treatment would come from over-riding their
autonomy.
Also, extrapolation from consent to tx for a minor wrt Gillick vs West (contraception)
and Fraser criteria (minor can consent if understand risks vs benefits, cannot be
persuaded to involve parents, tx in their ‘best interests’).
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A Colleague in Difficulty (Mr/Mrs Williams)
Student instructions for Doctor
You are a GP. Sean/Julie Williams is the next patient in your morning surgery. They are a surgeon at
the local hospital. You know them by good reputation and have heard them speak on a few
occasions. You see from their records that they usually see your partner and that the last entry in
the notes was scanty, alluding to stress at work.
Ascertain what he/she has come to see you about and try to help the best you can.
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A Colleague in Difficulty
Patient role
Background You are 30-45 year old Surgical Registrar at the local Trust. You have worked in the
operating theatres for 5 years and have, to date, been a highly respected surgeon. You are single but
have an on/off relationship with another doctor in the hospital. There has been a lot of restructuring
taking place at work, you find your colleagues distant and unsupportive and lately the pressure has
been getting to you. You have not been sleeping and, are feeling increasingly desperate and
depressed. You don’t have much experience of depression as an illness but you think you may have
it. About 6 months ago, began to drink whisky at bedtime to help you sleep. You are now drinking a
bottle a day. You have also used a few diazepam that an anaesthetist friend had ‘spare’!
You feel that your mood has continued to deteriorate and in the last 2 weeks you have taken a
‘dram’ of whisky before leaving for work at 7am. You have been careful to conceal the smell but are
worried that one theatre nurse may have smelled alcohol on your breath. You joked with her about
it and think that she was reassured but you are concerned for your reputation as you know how
gossip spreads in hospitals.
You have continued to operate three mornings a week and do not feel that your ability has been
impaired. There have been no untoward incidents to date.
Personal behaviour You have come to see your GP today. You want their help with your current
situation but do not want anyone at work to know. You report your ‘low mood’ as the problem but
will discuss openly your alcohol intake if questioned. You will not accept that your current drinking
habits are causing your problems or putting patients at risk. You will accept any help offered
regarding your stress levels but do not want to accept a sick note as you are worried what they will
put on it. You know that if you go off from work, this will be perceived as a sign of weakness and that
your colleagues will judge you for this. You will not speak with senior management and you do not
want occupational health involved. You are open to other suggestions.
Role play behaviour You are open about your predicament but firm about what help you are
prepared to accept. Start with something like ‘I’ve been struggling lately. I’ve been feeling really
stressed and I don’t like how it’s making me feel...’
A good student will want to assess your safety to continue working. If the student is empathetic but
firm about what must be done, accept that you have a responsibility to your patients to act safely
and accept their management plan. Ultimately, you know you will have to concede to their wishes
but would like a little tact around the way in which work is informed/advised of your absence. Eg a
sick note could say ‘stress’ or something else suitably vague at this stage.
If they become too ‘clinical’, say something like ‘I’d prefer to be the patient and let you be the
doctor, if that’s okay?’. If they use technical details that are unclear, either reflect the question back
‘What do you think?’ or admit that you don’t know what they mean. It would be perfectly legitimate
that a surgeon would not be up-to-date with management of depression/Occupational Health/sick
note certification/alcohol support services etc- this is the GP’s specialist area.
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Tutor notes for a Colleague in Difficulty- Sean/Julie Williams
Key ethical features autonomy vs patient safety
Key knowledge duty of care as per GMC guidance on ‘Duties of a Doctor’
Candidate expectation *firm but supportive stance
*listen carefully to what their colleague has to say
*elicit pt preferences around treatment options
*if their colleague will not act, they should be prepared to
Relevant information
Both you and your colleague/pt are bound by the GMC code.... as outlined in Good
Medical Practice (2013):
Protect patients and colleagues from any risk posed by your health
28. If you know or suspect that you have a serious condition that you could pass
on to patients, or if your judgement or performance could be affected by a
condition or its treatment, you must consult a suitably qualified colleague. You
must follow their advice about any changes to your practice they consider
necessary. You must not rely on your own assessment of the risk to patients.
[29. You should be immunised against common serious communicable diseases
(unless otherwise contraindicated).]
30. You should be registered with a general practitioner outside your family.
And from Raising and acting on concerns about patient safety (2012):
Duty to raise concerns
7. All doctors have a duty to raise concerns where they believe that patient safety
or care is being compromised by the practice of colleagues or the systems,
policies and procedures in the organisations in which they work. They must also
encourage and support a culture in which staff can raise concerns openly and
safely.
[8. You must not enter into contracts or agreements with your employing or
contracting body that seek to prevent you from or restrict you in raising concerns
about patient safety. Contracts or agreements are void if they intend to stop an
employee from making a protected disclosure.*]
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A similar case study with robust advice is out-lined below. Please note that Good Medical
Practice has been updated since but the basic principles remain the same.
A colleague under the influence
A GP sought advice about a female colleague who had been turning up late recently and
there was suspicions of alcohol abuse
Dr Catherine Wills, MDU medico-legal adviser
Publication date: 21 April 2006
A colleague under the influence
A GP member called the MDU Advisory Helpline to ask for advice about a female colleague
(a salaried GP employed by the PCT). He had noticed for some weeks that she had been
turning up late for surgery and for practice meetings. When she did attend meetings, she
rarely contributed and seemed distracted.
The member's call early in the New Year was prompted because things had come to a head
over the Christmas period: the practice nurse had reported that the female colleague had
smelled strongly of alcohol during surgery one day, and had been seen through the window
putting what appeared to be a small gin bottle in the bin outside the surgery on her way out to
do visits. The practice nurse had also witnessed a "near miss", when the GP had drawn up the
wrong injection to give to a patient.
The member said that he might not ordinarily have worried too much if a colleague had
obviously been drinking over the festive period, but he thought things in this case had "gone
too far".
The adviser reminded the member of his ethical duty, as set out by the GMC, to "protect
patients from risk of harm posed by another doctor's or healthcare professional's conduct,
performance or health, including problems arising from alcohol or substance misuse. The
safety of patients must come first at all times."1
The member had not spoken to the colleague in question, but after discussion he decided that
a reasonable first step would be for him to speak to her. They had always got on well, and he
hoped that she would value the support of being able to speak to somebody about her
problems.
The adviser pointed out to the member that, if he felt that the doctor's problem was posing a
risk to patients, the GMC would expect him to "give an honest explanation of [his] concerns
to an appropriate person from the employing authority".2
A doctor who feared that the health of a colleague might be placing patients at risk could be
called upon to justify a decision not to act on their concerns. However sympathetic to her he
felt, the member would need to be ready to speak to his colleague about the perceived
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problem. If he believed that she had a problem that might be placing patients at risk, and she
refused to do anything about it, he would need to be prepared, if necessary, to speak to an
appropriate officer of the PCT (such as the medical adviser) or refer the matter to the GMC if
local systems were unable to resolve the problem.
The member called back some days later, having discussed the situation with the doctor in
question. She had admitted heavy alcohol use, which she said was related to depression and a
difficult relationship at home. They had had a constructive discussion, following which she
had decided to take sick leave and see her own GP. She also planned to call the Sick Doctor's
Trust Helpline.3
The member thanked the adviser, saying that he had found it helpful to be able to discuss the
matter first with the MDU and be sure of his ground before having what could otherwise have
been a very difficult conversation.
Reference
1. Good Medical Practice, GMC, (May 2001).
2. ibid. paragraph 27.
3. The Trust's Helpline number is: 0870 444 5163; its web address is: www.sick-doctorstrust.co.uk. See also the article "Services for sick doctors: A changing but ongoing need" in
the October 2002 issue of The Journal of the MDU (Volume 18, Issue 2), p.10.
From www.the-mdu.com
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General Bibliography
www.bma.org.uk
www.gmc-uk.org especially Good Medical Practice 2013 and Interactive case studies from Good
Medical Practice 2013 see… http://gmc-gmpia.lightmaker.co.uk/index.asp
www.the-mdu.com
www.dh.gov.uk
www.dca.gov.uk/legal-policy
www.opsi.gov.uk/acts
Baxter, C, Brennan, MG, Caldicott, Y & Moller, M (2005) The Practical Guide to Medical Ethics &
Law, 2nd Edition, PasTest
Brazier, M & Cave, E (2011) Medicine, Patients and the Law, 5th Edition, Penguin Books
Kuhse, H & Singer,P (1999) Bioethics An Anthology, Blackwell Publishers
Searle, E, Sewart, A & Vernon, MJ (2006) Core Clinical Cases: Questions & Answers in Medical
Ethics, PasTest
Tutor notes updated: RB 27/6/14
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STUDENT HANDOUT
The following is a list of resources used in preparing this session which provides useful background
information.
Useful books
The first text would be ample if you are planning to invest. The second, part of the same series,
gives further examples of ethical scenarios.
Baxter, C, Brennan, MG, Caldicott, Y & Moller, M (2005) The Practical Guide to Medical Ethics &
Law, 5th Edition, PasTest
Searle, E, Sewart, A & Vernon, MJ (2006) Core Clinical Cases: Questions & Answers in Medical
Ethics, PasTest
DVLA/epilepsy
www.gmc-uk.org/guidance/current/library/confidentiality.asp#22
www.dvla.gov.uk medical rules ‘At a glance’
Safeguarding & 15y old with DM
http://www.gmc-uk.org/guidance/ethical_guidance/children_guidance_index.asp
http://www.gmcuk.org/publications/standards_guidance_for_doctors.asp#Protectingchildrenandyoungpeople
Negligent surgeon
www.the-mdu.com
www.gmc-uk.org Good Medical Practice (2013) including interactive case studies
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Additional Case Materials
Advanced decisions (Mr Seymour/Mrs Gale)
Student instructions
You are the on-call FY1 doctor, attached to a medical firm. You are asked to come and speak to the
son/daughter of Mr Ernest Seymour. Mr Seymour is a 72y old man who has been an in-patient for 2
days. He has end-stage Multiple Sclerosis and a chest x-ray has just confirmed pneumonia. As you
are led to the interviewing room by the staff nurse, she informs you that Mr Seymour has an
Advanced Directive in his records, it is legally robust and refuses active treatment should he contract
an infection; it specifically mentions pneumonia. Mr Seymour has given you permission to speak
openly with his son/daughter.
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Advanced decisions- Simulated patient role
Patient name Mr Seymour/Mrs Gale
Age
40-55
Sex
M/F
Ethnicity
(preferably) Black British
Setting
Ward sideroom
Background You are the son/daughter of Ernest Seymour. You live in Surrey and are recently
divorced. You have had a very stressful time of late due to the breakdown of your marriage and so
haven’t been as attentive to your father’s needs as you know you should have been. You know he
has Multiple Sclerosis (a deteriorating and, in this case, ultimately fatal illness) but he has always
been a very independent man, more so since your mother died from cancer 5 years ago. You have
not been involved in your father’s care. You were planning to visit your father in 2 weeks time having
not seen him for almost 12 months but have been prompted by your guilt and his admission to
hospital to attend sooner.
You have a sister who lives nearby. She has been attending to your father daily. You are not close
and she is resentful of your lack of involvement. Channels of communication are limited. You were
raised in a strictly Catholic household, but since your mother’s death, your father has renounced his
religion. You still attend mass regularly and hold a firm belief in the Catholic faith.
Reason for speaking to doctor You have arrived on the ward and found your father much changed
and very frail. The staff have advised you that your father has a pneumonia, confirmed on chest xray. Although your father is ill, he has conveyed to you that he is declining antibiotic treatment and
that this is a deliberate attempt to shorten his life. The staff have mentioned an ‘Advanced
Directive’- you do not understand what this means.
You are devastated by what you have seen and angry with your father that he is not ‘fighting’ this
illness. You are convinced that he is too ill to make a rational decision and want the hospital to override his refusal of treatment. His actions totally contradict what you were raised to believe about the
sanctity of life.
You have asked to speak to the doctor on the ward so that they can make your father start antibiotic
treatment.
Role play behaviour You are motivated by guilt but this is expressed as frustration rather than
anger. You are suspicious of authority and medicine and suspect there may be reasons why your
father is not being treated. You are keen to persuade the doctor that your parent must have been
coerced or lacking competence to agree to an Advanced Directive.
If the student displays good listening skills and empathy and establishes a rapport then be prepared
to listen to their explanations. Ultimately, I would hope that the student would be able to explain
the need to abide by the Advanced Directive and although you disagree with this you accept that
this has to be the plan.
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Tutor notes Advanced decisions- Mr Seymour
Key ethical features *pt’s legal right to choose medical treatment in advance of event.
Underpinned by Mental Capacity Act 2005 (MCA), legal since Oct 2007.
Key knowledge *What is an advanced directive/decision(AD)?
*What rights does this give a patient?
*What would constitute a legally binding AD?
*What rights does a relative have in these circumstances?
*Issues surrounding autonomy, capacity/competence and consent.
*Some details and understanding of MCA
Candidate expectation *Enough knowledge of an AD/MCA to advise correctly
*Good communication skills and sensitivity
*Robust exploration of ‘ideas, concerns and expectations’
*The ability to say ‘no’ but resolve conflict
Relevant information
MCA 2005 codifies law
(1) Assumption of capacity
(2) Enables decision making
(3) Unwise does NOT mean lack of capacity
(4) Best interests when lack capacity
(5) Least restrictive option when lack capacity (does not allow deprivation of
liberty)
Capacity –concept is task specific
(1) Understand
(2) Retain
(3) Use/weigh info
(4) Communicate decision
Now criminal offence to ill treat or wilfully neglect a person lacking capacity
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WRT Mr Seymour, he may lack capacity now but he will not have when his AD was
drawn up if it has been officiated. Although his lack of capacity is reversible, ie if
infection treated he would likely regain capacity, this is no reason to treat him against
an AD.
Advanced decisions
Written vs oral
Refusal/acceptance of treatment/ refusal of life-sustaining treatment= legally-binding
Preferences for tx= ‘guidance’
Limitations:
(1) Cannot demand treatment
(2) Cannot refuse treatment that would pose a threat to others
(3) Cannot refuse basic care (this is warmth, safety but not artificial hydration etc
and is open to debate in its interpretation)
Assume capacity when AD made.
Before the Act came into force, the courts had decided that some decisions were so serious that each case
should be taken to court so that a declaration of lawfulness could be made. The Act’s Code of Practice advises
that the following cases should continue to go before the court:

Proposals to withdraw or withhold artificial nutrition and hydration from patients in a persistent
vegetative state

Cases involving organ or bone marrow donation by a person lacking the capacity to consent

Proposals for non-therapeutic sterilisation

Some termination of pregnancy cases

Cases where there is a doubt or dispute about whether a particular treatment will be in a person’s
best interests

Cases involving ethical dilemmas in untested areas
Advance decisions refusing treatment
Although the legality of valid and applicable advance refusals of treatment has been established at common
law, [see reference 13] the Act provides welcome statutory clarification. The Act’s powers are restricted
explicitly to advance decisions to refuse treatment. Although broader general advance statements or ‘living
wills’ which indicate treatment preferences may well be relevant to a broader ‘best interests’ assessment, they
are not legally binding. An advance refusal of treatment is binding if:

The person making the directive was 18 or older when it was made, and had the necessary mental
capacity

It specifies, in lay terms if necessary, the specific treatment to be refused and the particular
circumstances in which the refusal is to apply
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
The person making the directive has not withdrawn the decision at a time when he or she had the
capacity to do so

The person making the directive has not appointed, after the directive was made, an attorney to make
the specified decision

The person making the directive has not done anything clearly inconsistent with the directive
remaining a fixed decision
Although advance decisions can be oral or in writing, an advance refusal will only apply to life-sustaining
treatment where it is in writing, is signed and witnessed, and contains a statement that it is to apply even
where life is at risk. Advanced decisions cannot be used to refuse basic care, which includes warmth, shelter
and hygiene measures to maintain body cleanliness. This also includes the offer of oral food and water, but not
artificial nutrition and hydration.
In an emergency or where there is doubt about the existence or validity of an advance directive, doctors can
provide treatment that is immediately necessary to stabilise or to prevent a deterioration in the patient until
the existence or applicability of the advance directive can be established.
from
www.bma.org.uk/ethics/consent_and_capacity/mencapact05.jsp
Relatives have no right to make decisions on behalf of pt’s whether an AD is in place or
not but best practice would say they should be informed/consulted when pt has lost
capacity.
Other resources
Can view MCA in it’s entirety at www.opsi.gov.uk/acts
www.dca.gov.uk ‘mental capacity act’
www.gmc-uk.org With-holding and withdrawing life prolonging treatments: Good
practice in decision-making
See also, MCA Toolkit (pdf) available c/o BMA website
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